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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 469-3420 Y'[w e �^-n NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete M Trlp9eetil — APPLICATION IB HERE BY MADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIES AMICAIMN IS MADE IN COMMANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-111�/�5 33 AND THE NDARDS OF SAN JOAQUIN COU7 PIIBUC H�E/A/ETN SERVICER.ENVIRONMENTAL HEALTH DMSION, JOB AOORESSHR AAP/N-C! �q p� Q L CIT.Y'J^/� c /L(/�Q PARCEL 91ZFlAPNI — OWNETS NAME_�/ [ ✓�- rFJ ADDRESS PO-:815y_ �� E.A.Q Q `PFIONE 0 CONTRACTOR Y r'/i E., r. / jJ �L–N M1DTMESS ��11c / L,� 7�.EP 11ClQp{IONE a/��--'�� RUIN CONTRACTOR ADDRESS UCI PHONE! TYPE OF WELUFUMP: ❑ NEW WELL ❑ RERACEMENT WELL ❑ MONITORING WELL! ❑ OTHER ��'')11��j.�– ❑ INSTALLATION ATION ❑ WILL BYSTEM REPAIR ❑ CROSS-0ONNECT REPAIR ❑ VAMP EXTRACTION WELL! J ❑Newy pe, N.P. I DEPT"MMP BErjrFT, FIRST WATER LEVEL�S�� O _ RYP OF RUMP, ❑ OVT-0f-SERVICE WELL ❑ GEOPHYSICAL WELL! ❑ BOIL WRING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A S ❑ INDUSTRIAL 11OM BOTTOM W.OF WELL EXCAVATION W.OF CONDUCTOR CASINO O DOMESTICRYSVATE 11 GRAVEL PACK/BRE TYPE OF CASIWUSMEL/PVC DIA.OF WELL CASINO O 9MBLMMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRWGATION/AG 11OTHEROTHER GREWSEAL INSTALLED BY GROUT BRAND NAME E V ❑ MONITONNG QR GROUT SEAL MMPFO: ❑Ys ❑Ne CONCRETE MMI TAL BY CISLLLSI:❑Yr ❑Ne S AFMOX.DEPTH c/ IIfS / LOCKING CHESTER BO%ISTOVE FIE S MOPOWD CGNSTRUCTONNRIWNG METHOD; MUD WEARY AIR WTARY AUGER CARLE OTHER / 1 HEREBY CERTIFY THAT I NAVE PREPARED THIS AfTtXATION AND THAT THE WOPR WILL.BE OEM IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN"AURIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOM MR WHICH Y� THIS PRMIT IB ISSUED,1 BULL WT EMPAY PERSONS SUBPE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES PL THE FOLLOWING: -I CLARIFY THAT IN TIN PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SNALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMM TON LAWS OF CALIFORNIA..- CAW MUST Cl*"HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION/AT F?mN 4W3 23. COMPLETE DRAWING AT LOWER AREA MOVIDEO. Slened POT PLAN 0—N,B W.I BF.IF •to I. NAMES OF STREETS OR WADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OISMSAL SYSTEM OR PROMSM 2. OUTLINE OF THE MORMY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISMBAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNUMD FIFTY TT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAWN. ON THE PROPERTY OR ADJOINING PIOP:RFY.